Simon Morgan

Identification of Aboriginal and Torres Strait Islander status in healthcare settings is essential for the delivery of culturally appropriate care. Under-identification is common and practitioner confidence is a known barrier. The objective of this research was to document the self-reported confidence of general practice registrars in identifying the Aboriginal and Torres Strait Islander status of their patients, and associations of this confidence. This research used cross-sectional analysis of survey and patient encounter data of general practice registrars training across five Australian states. Of the 698 registrars (97.5% response rate) who participated in the study, 74.5% had a high level of confidence in identifying a patient's Aboriginal and Torres Strait Islander status. Older and more senior registrars had significantly greater confidence. There was also a significant association with the registrars' training provider. More than a quarter of registrars reported low confidence for this basic consultation skill. Our findings will inform general prac-tice vocational training and continuing professional development, and reinforce the importance of a comprehensive, system-wide approach to the identification of patients' Aboriginal or Torres Strait Islander status.

General practice registrars in Australia are expected to identify and address their knowledge or skills gaps during consultations. The content and frequency of registrars seeking assistance and the factors that influence this have been studied for 84,723 consultations. Term 1 registrars asked their supervisor for help in 11.0% of consultations, but by term 4 this reduced to 1.2% of consultations. Assistance was most often for skin or musculoskeletal conditions, and more often about management than diagnosis. This article discusses the implications of this information for Australian general practice training. Registrars asked their supervisors for assistance despite having ready access to electronic information. Practices can anticipate supervisor interruptions approximately every tenth registrar consultation. The greater input required by registrars from supervisors earlier in training should be acknowledged by more flexible standards and payments to practices. A priority for general practice supervisor professional development is how to teach the management of complex patients, dermatology and musculoskeletal medicine.

There is concern about whether general practice registrars gain sufficient exposure to, and confidence in caring for, many pae-diatric conditions during their apprenticeship training. General practice registrars' referral patterns for paediatric conditions over-all or for specific conditions, including behavioural or mental health diagnoses, are unknown. The aim of this study was to assess the relative rates of referral by general practice registrars for children, compared with adults, specifically for those with behavioural or mental health diagnoses. A secondary analysis of 83,445 encounters from the Registrar Clinical Encounters in Training (ReCEnT) dataset was undertaken. More than half of children (52%) with a behavioural or mental health problem were referred to specialty care, compared with only 23% of adults. For all other conditions, only 9% of children received specialty referral, compared with 12% of adults. Although a certain proportion of behavioural or mental health issues in children may require either diagnostic assistance or aid in management, it is unclear whether more than half are unable to be cared for by a general practice registrar without referral.

Workplace-based formative assessments using consultation observation are currently conducted during the Australian general practice training program. Assessment reliability is improved by using multiple assessment methods. The aim of this study was to explore experiences of general practice medical educator assessors and registrars (trainees) when adding random case analysis to direct observation (ARCADO) during formative workplace-based assessments. A sample of general practice medical educators and matched registrars were recruited. Following the ARCADO workplace assessment, semi-structured qualitative interviews were conducted. The data was analysed thematically. Ten registrars and eight medical educators participated. Four major themes emerged - formative versus summative assessment; strengths (acceptability, flexibility, time efficiency, complementarity and authenticity); weaknesses (reduced observation and integrity risks); and contextual factors (variation in assessment content, assessment timing, registrar-medical educator relationship, medical educator’s approach and registrar ability). ARCADO is a well-accepted workplace-based formative assessment perceived by registrars and assessors to be valid and flexible. The use of ARCADO enabled complementary insights that would not have been achieved with direct observation alone. Whilst there are some contextual factors to be considered in its implementation, ARCADO appears to have utility as formative assessment and, subject to further evaluation, high-stakes assessment.

Background: Travel medicine is a common and challenging area of clinical practice and practitioners need up-to-date knowledge and experience in a range of areas. Australian general practitioners (GPs) play a significant role in the delivery of travel medicine advice. We aimed to describe the rate and nature of travel medicine consultations, including both the clinical and educational aspects of the consultations. Methods: A cross-sectional analysis from an ongoing cohort study of GP trainees’ clinical consultations was performed. Trainees contemporaneously recorded demographic, clinical, and educational details of consecutive patient consultations. Proportions of all problems/diagnoses managed in these consultations that were coded “travel-related” and “travel advice” were both calculated with 95% confidence intervals (CIs). Associations of a problem/diagnosis being “travel-related” or “travel advice” were tested using simple logistic regression within the generalized estimating equations (GEE) framework. Results: A total of 856 trainees contributed data on 169,307 problems from 108,759 consultations (2010–2014). Travel-related and travel advice problems were managed at a rate of 1.1 and 0.5 problems per 100 encounters, respectively. Significant positive associations of travel-related problems were younger trainee and patient age; new patient to the trainee and practice; privately billing, larger, urban, and higher socioeconomic status practices; and involvement of the practice nurse. Trainees sought in-consultation information and generated learning goals in 34.7 and 20.8% of travel advice problems, respectively, significantly more than in non-travel advice problems. Significant positive associations of travel advice problems were seeking in-consultation information, generation of learning goals, longer consultation duration, and more problems managed. Conclusions: Our findings reinforce the importance of focused training in travel medicine for GP trainees and adequate exposure to patients in the practice setting. In addition, our findings have implications more broadly for the delivery of travel medicine in general practice.Simon Morgan, Kim M. Henderson, Amanda Tapley, John Scott, Mieke L. van Driel, Neil A. Spike, Lawrie A. McArthur, Andrew R. Davey, Nigel F. Catzikiris and Parker J. Magi

Objective: To establish prevalence and associations of general practice nurses’ (GPNs) involvement in general practitioner (GP) registrars’ consultations. Methods: A cross-sectional analysis from an ongoing cohort study of registrars’ clinical consultations in five Australian states. Registrars recorded detailed data from 60 consecutive consultations per 6-month training term. Problems and diagnoses encountered, including chronic disease classification, were coded using the International Classification of Primary Care, second edition duplication system (ICPC-2plus) classification system. The outcome factor in our analysis was GPN involvement in management of individual problems and diagnoses. Independent variables were a range of patient, registrar, practice, consultation and educational factors. Results: We analysed 108 759 consultations of 856 registrars including 169 307 problems or diagnoses. Of the problems/diagnoses, 5.1% (95% confidence interval (CI) 5.0–5.2) involved a GPN. Follow-up with a GPN was organised for 1.5% (95% CI 1.4–1.5) of all problems/diagnoses. Significant associations of GPN involvement included patient age, male sex, Aboriginal or Torres Strait Islander status, non-English-speaking background (NESB) and the patient being new to the practice. Larger practice size, the particular training organisation, and the problem/diagnosis being new and not a chronic disease were other associations. Conclusions: Associations with Aboriginal or Torres Strait Islander status and NESB status suggest GPNs are addressing healthcare needs of these under-serviced groups. But GPNs may be underutilised in chronic disease care. What is known about this topic?: GPNs are increasingly involved in team-based care in Australian general practice. The potential positive contribution of GPNs to general practice teams is acknowledged, but the role of the GPN is still being refined. What does this paper add?: GPNs contribute to the care of a modest proportion of patients seen by GP registrars. Aboriginal or Torres Strait Islander status and NESB of patients are positively associated with being seen by a GPN; chronic disease is negatively associated with being seen by a GPN. There is geographic variability in prevalence of GPN consultations, not explained by other factors. What are the implications for practitioners?: Given the match of GPN skills and attributes to the needs of patients with chronic diseases, GPNs currently may be underutilised in chronic disease care in Australian general practice. The marked geographic variation in uptake of GPNs also suggests scope for greater utilisation of GPNs Australia-wide.

As usual, I finished with a cartoon. It pictured a patient sitting on the examination couch with a spear through his head and the white-coated doctor saying ‘I’m pretty sure I know what the problem is, but just to be sure I’m ordering a battery of tests. ’ It had been a provocative session. I had presented on the exponential increase in test ordering over recent decades, and the consequent costs (real and opportunity) to health systems around the world.1 We had discussed the challenges of managing ‘incidentalomas’, illustrated by a recent patient I had looked after with an angiomyolipoma of the kidney identified as a result of a request for a scrotal ultrasound. No word of a lie. And we debated the very real …

INTRODUCTION: Fatigue is the most common undifferentiated problem presenting in general practice. Previous studies have shown that this presentation leads to multiple investigations. There is no published literature describing the management of patients with fatigue by general practice (GP) registrars. AIM: To document the investigation-ordering behaviour of GP registrars in managing patients with a new diagnosis of unexplained fatigue. METHODS: This was a cross-sectional analysis of data from Registrar Clinical Encounters in Training (ReCEnT), an ongoing cohort study of GP registrars? consultations. We established the prevalence of new diagnoses of unexplained fatigue and associations with that diagnosis, the rate of test ordering and the number and types of investigations ordered. RESULTS: 644 registrars contributed data from 68 986 encounters. In 0.78% of patient encounters, a new diagnosis of unexplained fatigue was made. Pathology was ordered in 78.4% of these problems (versus 18.1% in non-fatigue problems), at a rate of 488 tests per 100 new fatigue problems. DISCUSSION: Our study suggests that unexplained fatigue elicits a non-rational approach to test ordering by registrars. These findings contribute to the understanding of GP registrar management of fatigue, and undifferentiated presentations more broadly, and suggest educational approaches to improve practice, including dealing with uncertainty. KEYWORDS: Diagnostic tests, routine; education, medical; family practice; fatigue; general practice